Impact of Non-rib-Spreading, 3D Fully Endoscopic, Mini Incision Technique for Mitral Valve Repair on Quality of Life and Postoperative Pain - A Matched-pair Analysis of 200 Patients

Objectives: Advances in video-assistance lead to an increase of minimally invasive mitral valve surgery (MIMVS) with decreased incision size, and at the same time improved visual guidance. Further reduction of invasiveness by a non-rib-spreading (NRS) 3D fully endoscopic technique leads to quicker postoperative recovery and reduced pain. Methods: Since June 2013 fully endoscopic NRS-MIMIVS was performed in 100 patients (43% female, age 56.9 ± 12.2 years) with a 3–4cm incision in the inframammary fold through the fourth intercostal space, using only a soft-tissue-retractor . In 10 male patients reduced incision along the periareolar margin was performed. Visualization was provided by 3D-endoscopy in 80 patients. The NRS-MIMIVS group was matched with 100 patients who underwent standard rib-spreading (RS-)MIMVS (36% female, age 58.7 ± 13.3 years). Surgical data, repair results, NYHA, pain-scales and freedom from MACCE were compared early postop and at 1 year follow-up. 3 month follow-up was 98% complete in both groups, 1-year follow-up was 98% complete in 50 patients of the NRS-MIMVS group and 98% in the RS-MIMVS group. Results: Valve repair was successful in all patients without technical limitations. Mortality was 0% in both groups. Significant differences between groups were seen for operation times (delta = 26.6 minute shorter in the NRS group, p < 0.001), and length of stay on ICU (delta = 0.9 days shorter in the NRS group, p = 0.001) and in hospital (delta = 1.7 days shorter in the NRS group, p < 0.001). Ventilation-times on ICU were shorter in the NRS-group (delta = 2.0 hour; p = 0.003). Postoperative pain rated on a pain-scale from 0–10 was significantly lower in the NRS group (delta= 0.6; p = 0.030). Follow-up echocardiography showed sufficient repair in all patients of both groups with 88% showing no recurrent MR and 12% ≤ grade 1 in the NRS group versus 84% no recurrent MR and 16% ≤ grade 1 in the RS group after 3 months (at 1 year follow-up: 86% no MR, 4% ≤ grade 1 versus 85% no MR, 5% ≤ grade 1 (NRS versusRS)). Patients of both groups showed significantly improved NYHA classes early postoperative and after 1 year without significant differences between groups. Conclusion: A less invasive procedure supported by 3D-visualization leads to shorter operation times, early mobilization and shorter hospitalization with reduced postoperative pain, while maintaining consistent quality of repair results.